Information Collection

Employer Notification Request to HHS of its Objection to Providing Contraceptive Services – Self-Certification

IC 212753 under ICR 201411-0938-002 · OMB 0938-1248.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1248 can be found here:

Documents and Forms

Document Name Document Type
CMS-10535_Model Notice_8_14_14.pdf Model Notice IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employer Notification Request to HHS of its Objection to Providing Contraceptive Services â Self-Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(c)(1) 45 CFR 147.131(b)(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 122	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	122	122
Annual IC Time Burden (Hours)	110	110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Model Notice	CMS-10535_Model Notice_8_14_14.pdf	08/21/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.